OCR Rendition - approximate

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Eugenics as a Creed and the Last Decade of Galton's Life 295

Register

Initials

I Notable achievements of any brother or sister of the Father of the Applicant that fall within the purview of this Certificate

We certify that to the best of our knowledge the above account is correct, also that with the exceptions mentioned below, no member of this Fraternity has ever suffered from Insanity, Epilepsy or other severe form of nervous disease.

Exceptions giving full particulars. If no
exceptions write the word " None "

Writer of the above notice.

Signatures of The Applicant.

QUESTIONS C, CONCERNING THE KINDRED OF THE APPLICANT.

On the Fraternity consisting of the Mother of the Applicant and of the Mother's whole brothers and sisters. Write M by the side of the figure in the first column that refers to the Mother, and describe her achievements more fully than those of her sisters.

 

Register	Names or Initials in order of Birth		Sex M..or F.	It' deceased
				Age at Death	Cause of Death
1 2 3
Register	Initials	Notable achievements of any brother or sister of the Mother of the Applicant that fall within the purview of this Certificate

We certify that to the best of our knowledge the above account is correct, also that with the exceptions mentioned below, no member of this Fraternity has ever suffered from Insanity, Epilepsy or other severe form of nervous disease.

Exceptions giving full particulars. If no
exceptions write the word "None"

Writer of the above notice.

Signatures of The Applicant.

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